N. M. van Hemel

Long-term results of the corridor operation for atrial fibrillation.

OBJECTIVE--To investigate the long-term results of the corridor operation in the treatment of symptomatic atrial fibrillation refractory to drug treatment. BACKGROUND--The corridor operation is designed to isolate from the left and right atrium a conduit of atrial tissue connecting the sinus node area with the atrioventricular node region in order to preserve physiological ventricular drive. The excluded atria can fibrillate without affecting the ventricular rhythm. This surgical method offers an alternative treatment when atrial fibrillation becomes refractory to drug treatment. PATIENTS--From 1987 to 1993, 36 patients with drug refractory symptomatic paroxysmal atrial fibrillation underwent surgery. The in hospital rhythm was followed thereafter by continuous rhythm monitoring and with epicardial electrograms. After discharge Holter recording and stress testing were regularly carried out to evaluate the sinus node function and to detect arrhythmias; whereas Doppler echocardiography was used to measure atrial contraction and size. MAIN OUTCOME MEASURES--Maintained absence of atrial fibrillation without drug treatment after operation; preservation of normal chronotropic response in the sinus node. RESULTS--The corridor procedure was successful in 31 (86%) of the 36 patients. After a mean (SD) follow up of 41 (16) months 25 (69%) of the 36 patients were free of arrhythmias without taking drugs (mean (SE) actuarial freedom at four years 72 (9)%)). Paroxysmal atrial fibrillation recurred in three patients; paroxysmal atrial flutter (two patients) and atrial tachycardia (one patient) developed in the corridor in three others. Among the 31 patients in whom the operation was successful sinus node function at rest and during exercise remained undisturbed in 26 and 25 patients respectively (mean (SE) actuarial freedom of sinus node dysfunction at four years (81(7)%)). Pacemakers were needed in five (16%) of the 31 patients for insufficient sinus node rhythm at rest only. Doppler echocardiography showed maintenance of right atrial contribution to right ventricle filling in 26 of the 31 patients after operation in contrast to the left atrium, which never showed such contribution. His bundle ablation was performed and a pacemaker implanted in the five patients in whom the corridor operation was unsuccessful. CONCLUSION--These results substantiate the idea of this surgical procedure. Modification of the technique is, however, needed to achieve a reliable isolation between left atrium and corridor, which would make this experimental surgery widely applicable in the treatment of drug refractory atrial fibrillation.

Myocardial adaptation in different endurance sports: an echocardiographic study

Objective: Of this study was to investigate three groups of highly trained competitive endurance athletes consisting of marathon runners, triathletes and cyclists for differences in left ventricular adaptation. Methods: 25 marathon athletes, 21 triathlon athletes and 38 cyclists underwent a standard echocardiographic and Doppler study. Results: The left ventricular internal diameter in diastole divided by body surface area was significantly larger in cyclists than in marathon runners (31.6 ± 3.0 vs. 30.0 ± 2.0 mm/m2, p < 0.05) but did not differ of that of triathletes. Left ventricular mass was significantly different between marathon runners and triathletes (253.6 ± 63.7 vs. 322.0 ± 62.1 g, p < 0.005) and between marathon runners and cyclists (253.6 ± 63.7 vs. 314.2 ± 79.2 g, p < 0.005). Systolic wall stress was significantly different between the marathon runners and the triathletes (88.4 ± 11.7 vs. 78.9 ± 11.0 g/cm2p < 0.05). Only a minority of the endurance athletes showed concentric remodeling (7%), whereas a majority showed eccentric remodeling (65%) of the left ventricle. The prevalence of eccentric remodeling was more apparent in cyclists. There were some specific differences in left ventricular diastolic function between the three different endurance sports, but no left ventricular diastolic dysfunction could be detected. Conclusion: There is a sport-specific left ventricular adaptation in endurance athletes. The triathlon heart and the heart of a cyclist differ significantly from a marathon heart.

Remote monitoring and follow-up of cardiovascular implantable electronic devices in the Netherlands: An expert consensus report of the netherlands society of cardiology

Remote monitoring of cardiac implanted electronic devices (CIED: pacemaker, cardiac resynchronisation therapy device and implantable cardioverter defibrillator) has been developed for technical control and follow-up using transtelephonic data transmission. In addition, automatic or patient-triggered alerts are sent to the cardiologist or allied professional who can respond if necessary with various interventions. The advantage of remote monitoring appears obvious in impending CIED failures and suspected symptoms but is less likely in routine follow-up of CIED. For this follow-up the indications, quality of care, cost-effectiveneness and patient satisfaction have to be determined before remote CIED monitoring can be applied in daily practice. Nevertheless remote CIED monitoring is expanding rapidly in the Netherlands without professional agreements about methodology, responsibilities of all the parties involved and that of the device patient, and reimbursement. The purpose of this consensus document on remote CIED monitoring and follow-up is to lay the base for a nationwide, uniform implementation in the Netherlands. This report describes the technical communication, current indications, benefits and limitations of remote CIED monitoring and follow-up, the role of the patient and device manufacturer, and costs and reimbursement. The view of cardiology experts and of other disciplines in conjunction with literature was incorporated in a preliminary series of recommendations. In addition, an overview of the questions related to remote CIED monitoring that need to be answered is given. This consensus document can be used for future guidelines for the Dutch profession.

Exercise capacity after His bundle ablation and rate response ventricular pacing for drug refractory chronic atrial fibrillation

OBJECTIVE: To evaluate exercise capacity of patients with chronic atrial fibrillation in whom His bundle ablation followed by ventricular rate response pacing (VVIR) was carried out because of drug refractoriness. DESIGN: Prospective study. PATIENTS: 25 consecutive patients, all with chronic symptomatic drug refractory atrial fibrillation, underwent His bundle ablation. Before this intervention all patients were on antiarrhythmic drugs to attain acceptable heart rate control and to relief symptoms. MAIN OUTCOME MEASURES: Exercise capacity, including measurements of VO2, was examined before and after a mean interval of seven months following His bundle ablation. RESULTS: Exercise capacity after His bundle ablation increased from a mean of 109 (SD 49) W to 118 (46) W (P < 0.002), but VO2 at peak exercise did not change significantly. Maximum exercise capacity was achieved with a significantly lower maximum driven heart rate than the spontaneous heart rate before ablation. CONCLUSIONS: Exercise capacity of patients who underwent His bundle ablation followed by VVIR pacing remained unchanged or improved during a mean follow up of seven months. Larger patient populations with longer follow up are necessary to examine determinants of improved exercise capacity.

Initial Clinical Experience with Rate Adaptive Cardiac Pacing Using Two Sensors Simultaneously

LANDMAN, M.A.J., ET AL.: Initial Clinical Experience with Rate Adaptive Cardiac Pacing Using Two Sensors Simultaneously. In the rate adaptive pacemakers, all presently available sensors show one or more drawbacks. Combining two sensors in a single pacemaker, we tried to optimize its rate responsive characteristics. In this study, we present the rate adaptive behavior of a two sensor pacemaker system, using both QT interval and activity sensing. In addition, we compared the rate response with that of each sensor alone. Nine patients with an implanted QT interval sensing pacemaker, and an externally attached activity sensing pacemaker performed three exercise stress tests on treadmill. The QT interval, measured by the implanted pacemaker, and the activity level, were transmitted to an external computer. This computer contained the two sensor rate adaptive algorithm, and reprogrammed the implanted pacemaker on beat‐to‐beat basis. Conclusion: In the two sensor mode the rate increases immediately at the onset of exercise, caused by the prompt response of the activity sensor. Further rate increase is driven by the QT interval sensor and therefore proportional to the level of exercise. Furthermore, the rate decay during the recovery phase is more physiological.

Ten Year Follow‐Up After Radiofrequency Catheter Ablation for Atrioventricular Nodal Reentrant Tachycardia in the Early Days Forever Cured, or a Source for New Arrhythmias?

Background: Radiofrequency (RF) catheter ablation is highly effective with a low complication rate. However, lesions created by RF energy are irreversible, inhomogeneous, and therefore potentially proarrhythmic.

Remote monitoring of implanted cardiac devices: a plea for a nationwide exploration

Remote monitoring of implanted cardiac devices is an evolving method for regular checks of their electronic integrity and functioning. The communication with the devices is carried out unsupervised with wireless trans-telephonic or cable-dependent linkage. The interrogation of the device examines several programmed functions and harvests the stored data of numerous events. The collected data constitute the base to decide whether the implanted device is operating properly and can give some information about the physical condition of the device recipient. Preliminary short-term results show favourable effects in terms of safety and cost and time saving as compared with the current face-to-face visits of conventional patient follow-ups. Remote monitoring of implanted devices will extend markedly in the coming years and its development touches many questions ranging from technical accuracy, patient benefit, cost-effectiveness and responsibilities of the provider and receivers of the delivered device data, to the role of the cardiologist and allied professionals and of course privacy rules. In this point of view, these questions are discussed in order to explore the consequences of device remote monitoring with nationwide Trials. (Neth Heart J 2009;17:434–7.)

8 October 1958, D Day for the implantable pacemaker.

AbstracAfter the introduction of temporary transcutaneous cardiac pacing by Paul Zoll in 1952, and of the temporary endocardial approach by Seymour Furman in the USA in 1958, the first definitive electronic pacemaker was implanted by Senning and Elmqvist in Sweden on 8 October 1958 using a thoracotomy to suture two epicardial electrodes. Actually, the ‘definitive’ unit placed in the abdominal wall of the pacemaker recipient, Arne Larsson, fired for only three hours. The first replacement, done the following morning, was followed by more than 22 units and numerous surgical interventions until Mr Larsson died in 2001.

Cardiac resynchronisation therapy in daily practice and loss of confidence in predictive techniques to response.

Cardiac resynchronisation therapy (CRT) aims to restore left ventricular electrical/mechanical dyssynchrony, which can underlie impaired systolic left ventricular (LV) function and congestive heart failure. Several large prospective studies were able to document clearly that chronic electrical synchronisation does improve the systolic dysfunction and ameliorates symptoms, patient functioning and prognosis. If the conventional criteria are applied, this positive response can be observed in roughly 70% of patients, depending on the definition used for ‘positive response’.

Quality of care: not hospital but operator volume of pacemaker implantations counts

Literature about pacemaker (PM) implantations shows that several clinical and technical factors determine the short- and long-term complications after the intervention. Annual hospital volume, however, does not negatively affect complications in contrast with the cumulative experience of the operator. In view of this observation, the current required number of 20 to 30 first PM implantations for cardiology training does not match standards for quality of care. In addition, concentration of implants and replacement of pacemakers to a limited number of operators per hospital to comply with the increasing demands of patients and other parties has to be seriously considered.